Indications for Beta-Blockers in HFpEF

Expert Analysis

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Rationale for Study:1
To determine if older adults hospitalized for heart failure with preserved ejection fraction (HFpEF) had compelling indications to receive beta-blockers.

Funding:
National Institute on Aging; National Heart, Lung, and Blood Institute; National Institute of Neurological Disorders and Stroke; National Institutes of Health; Department of Health and Human Service.

Methods:
In this retrospective, observational study, the investigators sampled HFpEF hospitalizations in patients aged 65 years or older between 2003 and 2014 using the participants from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. The REGARDS study originally recruited African-American and white adults from the United States (with planned oversampling of the South) between 2003 and 2007 with longitudinal follow-up for a prospective, observational analysis.2 In this current study, the investigators used expert clinical adjudicators to determine HFpEF hospitalization (EF ≥50% documented within 6 months of hospitalization). The authors included repeated hospitalizations that were >90 days of a previous eligible hospitalization. Discharge medications were reviewed for the included hospitalizations and the medical record was abstracted to determine the indication for beta-blocker use. The investigators classified the beta-blocker indication in two groups as "compelling", including a history of myocardial infarction (MI), atrial, or ventricular arrhythmias; and "noncompelling", including hypertension, coronary artery disease (CAD) without MI, or unknown (where no clear indication was available). The prevalence of geriatric conditions (consisting of functional limitations, cognitive impairment, hypoalbuminemia, and history or falls) were included and stratified by beta-blocker indication.

Results:
A total of 306 HFpEF hospitalizations (including 254 patients from 202 unique hospitals) were examined. Beta-blockers were prescribed on discharge for 68% of these hospitalizations (87% of these patients were taking a beta-blocker as a home medication). Among these hospitalizations 60% of beta-blocker use was deemed to be compelling (43% atrial arrhythmias, 4% ventricular arrhythmias, and 29% history of MI). The 40% with noncompelling indications included 57% with CAD, 38% with hypertension, and 5% with no documented indication. Of the patients receiving a beta-blocker on discharge, 69% of them had geriatric conditions (38% hypoalbuminemia, 26% functional limitations, 26% history of falls, and 14% cognitive impairment). The authors did not find a significant difference in the prevalence of geriatric conditions between beta-blocker indication groups.

Limitations of study:
While beta-blocker prescribing in noncompelling indications was common, it is not known whether patient preferences or contraindications precluded the use of medication classes with stronger evidence of support in these indications. It is also of note that the authors could not reliably assess angina as an indication for beta-blockers due to limitations of documentation in the data. Lastly, within the compelling indication group, the timing of MI was not captured and may in fact overestimate the indication given data suggesting beta-blockers are beneficial for 3 years post-MI.

Take Home Message:
Randomized clinical trials have failed to demonstrate a benefit of beta-blockers within a HFpEF population. Despite that, as this study demonstrates, use was common after HFpEF hospitalization even when compelling indications were not noted. Concerns for beta-blocker use include chronotropic incompetence and adverse drug effects (e.g. confusion, fatigue, symptomatic bradycardia, and heart block), conditions to which elderly patients are frequently predisposed. This study reaffirms the need to continually reassess risks and benefits of medications especially in an elderly population where polypharmacy is so common. While beta-blockers may be an important target for deprescribing in elderly patients, a paucity of data exists on the safest way to discontinue them. The authors highlight the need for more research into developing these protocols.